Prevention of Future Deaths reports · 2019

Richard Hallett

Regulation 28 report to prevent future deaths, reference 2019-0189, written 6 Jun 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report6 Jun 2019
Reference2019-0189
DeceasedRichard Hallett
CoronerBrendan Allen
Coroner areaDorset
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

1. |] The Duchy of Cornwall, Poundbury Farmhouse,
Poundbury Farm Way, Dorchester. DT1 3RT

1 | CORONER

Iam Brendan Joseph Allen, Assistant Coroner, for the Coroner Area of Dorset.

2 | CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.

3 | INVESTIGATION and INQUEST

On the 21% September 2018, an investigation was commenced into the death
of Richard Stanley Lee Hallett, who was born on the 11 June 1993.

The investigation concluded at the end of the Inquest on the 29" May 2019.
The Medical Cause of Death was:
Ta Severe Head Injury

The conclusion of the Inquest was Richard Stanley Lee Hallett died as a
consequence of a road traffic collision.

4 | CIRCUMSTANCES OF THE DEATH

On 14 September 2018, Mr Hallett was riding a motorcycle in a westerly
direction along Harewood Road in Poundbury. As he approached the junction
with Lower Blackmere Road, a white Iveco van was approaching the same
junction, travelling in a northerly direction along Lower Blakemere Road. Mr
Hallett’s motorcycle collided with the driver's side wing of the Iveco van. He
sustained severe head injuries and was taken to Southampton Hospital. Despite
surgical intervention, Mr Hallett died at Southampton Hospital on 16%
September 2018.

CORONER'S CONCERNS

During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless
action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:

1. During the inquest evidence was heard that:

i. There are no road markings in the Poundbury estate to indicate
which vehicle has the right of way when reaching a junction. In
addition, parking appears to be permitted along the length of
Lower Blakemere Road, which forces vehicles travelling in a
northerly direction into the oncoming carriageway. Police
evidence indicated that this reduced the sightline of the driver
of the Iveco van when looking into Harewood Road to look for
oncoming traffic.

2. Ihave concerns with regard to the following:

i. The lack of parking restrictions on Lower Blakemere Road result
in the drivers that use that road having a reduced sightlines
when approaching junctions. Such drivers are not able to see
traffic approaching the junctions until very late, and as no
vehicle would appear to have right of way, the risk of collision
would appear to be increased.

ACTION SHOULD BE TAKEN

In my opinion urgent action should be taken to prevent future deaths and I
believe you and/or your organisation have the power to take such action.

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of
this report, 2"? August 2019. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action
is proposed.

COPIES and PUBLICATION

I have sent a copy of my report to the Chief Coroner and to the following
Interested Persons:

(1) Tina Cooper, mother of Richard Hallett;
(2) Mr Andrew Bell, the driver of the white Iveco van mentioned above.

Tam also under a duty to send the Chief Coroner a copy of your response.

The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the coroner, at the time of your response, about the release or the publication
of your response by the Chief Coroner.

Dated

BrendarJ Allen

6 June 2019

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Duchy of Cornwall (PDF)
DUCHY  /CORNWALL

POUNDBURY OFFICE, POUNDBURY FARMHOUSE, POUNDBURY FARM WAY, POUNDBURY,

DORCHESTER, DORSET DTI  3RT

, Estates Director for the Duchy of Cornwall

Mr B J Allen
H M Acting Senior Coroner for Dorset
The Coroner’s Office for the County of  Dorset
Town Hall
Bournemouth BH2 6DY

Dear Mr Allen

Richard Stanley Lee Hallett Deceased

Thank you for your letter of  7 June. I have carefully considered the points you have raised
and can reply as follows.
l.i. 

“There  are  no  road  markings  in  the  Poundbury  estate  to  indicate  which
vehicle  has  the right  of way when  reaching a  junction.  In  addition,  parking
appears to  be  permitted  along  the  length  of Lower  Blakemere  Road, which
into  the  incoming
forces  vehicles  travelling  in  a  northerly  direction 
carriageway. Police  evidence  indicated  that this  reduced the  sightline  of  the
driver  of  the  Iveco  van  when  looking  into  Harewood  Road  to  look  for
oncoming traffic.”

The  extent  of  road  markings  and  general  signage  is  purposely  restricted  as  part  of  the
highway design, with approval from Dorset Council Highways Department. The approach
being to;

a.  Place more immediate responsibility on road users rather than reliance on

markings and signage

b.  Establish individual engagement, including eye contact, between highway

users, be they vehicular, motorcycle, cycle or pedestrian

2.i 

“The  lack  of  parking  restrictions  on  Lower  Blakemere  Road  result  in  the
drivers  that  use  that  road  having  a  reduced  sightlines  when  approaching
junctions.  Such  drivers  are  not  able  to  see  traffic  when  approaching  the
junctions until very late, and as no vehicle would appear to have right of way,
the risk of collision would appear to be increased.”

There  is  no  formal  parking  restriction  in  Lower  Blakemere  Road,  in  common  with  the
majority of  Poundbury. This does not alter the requirement on individuals to park safely
and in accordance with the Highway Code.

 With  the  exception  of  the  tragic  incident  on  14  September  2018,  Dorset  Council
Highways have confirmed there have been no other serious occurrences at this site. I am
also  assured  by  Dorset  Council  and  our  own  Highway  Design  Consultants,  having
themselves reviewed the accident data for 2014-2018 for Poundbury and Dorchester, that
there does not appear to be any pattern or clustering of  accidents within Poundbury which
would suggest that there are not any particular ‘black spots’.

However, to reduce the possibility of  a repetition, I can advise that we have reviewed the
location  and  identified  measures  to  restrict  parking  in  the  immediate  vicinity  of  the
junction. This is  proposed to  be in the form of  two  additional parking bollards on  each
approach,  set  back  from  the  junction,  deterring  cars  from  parking  immediately  by  the
crossing. The proposals have been submitted to Dorset Council Highways Department for
approval. Subject to such approval, they will be installed as soon as practicably possible,
with a longstop of  31 October 2019.

1 trust you will contact me if  you require any further clarification.

Yours sincerely

Estates Director

2

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